Genital Warts (Human Papillomavirus)

Topic Overview

Is this topic for you?

This topic provides information about the
human papillomavirus (HPV), which causes
genital warts and can also cause cervical cancer. If
you are looking for information about cervical cell changes or
cervical cancer, see:

What is human papillomavirus (HPV)?

Human
papillomavirus (HPV) is one of the most common
sexually transmitted infections (STIs). It is a virus
that can be spread through skin-to-skin genital contact. There are many different types
of HPV. Some types cause genital warts and are called low-risk. And some types
can lead to cervical, anal, or oral cancer and are called high-risk. There is no known cure
for HPV, but there is a vaccine that can protect against some types of the
virus.

What are genital warts?

Genital warts are skin
growths in the groin, genital, or anal areas. They can be different sizes and
shapes. Some look like flat white patches, and others are bumpy, like tiny
bunches of cauliflower. Sometimes you can't see the warts at all.

What causes HPV and genital warts?

HPV is a virus.
Certain types of the virus cause genital warts and some types cause abnormal
cervical cell changes and cervical cancer.

HPV and genital warts
can be spread through sex or skin-to-skin genital contact with someone who has the virus.

What are the symptoms?

Most people infected with
HPV don't have symptoms. But if they do, the symptoms may be so mild that they
may not know they are infected. The symptoms may include pain, itching, and
bleeding, or you may develop visible genital warts.

If you have
symptoms, they will probably occur 2 to 3 months after infection. But you can
have symptoms from 3 weeks to many years after infection.

Visible
genital warts appear only during active infection. But it is possible to spread
the virus even if you can't see the warts.

How are HPV and genital warts diagnosed?

A doctor
can often tell if you have genital warts by looking closely at your genital and
anal areas. He or she may ask you questions about your symptoms and your risk
factors. Risk factors are things that make you more likely to get an infection.

Sometimes the doctor takes a sample of tissue from the wart for
testing.

For women, if you have an abnormal Pap test, your doctor
can do an HPV test that looks for high-risk types of the virus.

How are they treated?

There is no cure for HPV,
but the symptoms can be treated.

Talk to your doctor about whether
you should treat visible genital warts. They usually go away with no treatment,
but they may also spread. Most people decide to treat them because of the
symptoms or because of how the warts look. But if you don't have symptoms and
are not worried about how the warts look, you can wait and see if the warts go
away.

If you do decide to treat genital warts, talk to your
doctor about the best treatment for you. There are prescription medicines that you
or your doctor can put on the warts. Or your doctor can remove them with
lasers, surgery, or by freezing them off.

Even if you treat
visible warts or your warts go away without treatment, the HPV infection can
stay in your body's cells. It is possible to spread genital warts to your
partner even if you have no signs of them.

Can HPV and genital warts be prevented?

The best way to
keep from getting genital warts-or any other STI-is to not have sex or any skin-to-skin genital contact. If you do
have sex, practice safer sex.

Use condoms. Condoms may help reduce the risk
of spreading genital warts, but they do not protect the entire genital area
against skin-to-skin contact.

Before you have sex with someone,
talk to them about STIs. Find out whether he or she is at risk for them.
Remember that a person can be infected without knowing it.

If you
have symptoms of an STI, don't have sex.

Do not have sex with
anyone who has symptoms or who may have been exposed to an STI.

Having several sex partners
increases your risk for infection.

If you are age 26 or younger, you can get the HPV shot. The vaccines Cervarix(What is a PDF document?) and Gardasil(What is a PDF document?) protect against two types of HPV that cause cervical cancer. Gardasil also protects against two types of HPV that cause genital warts.

Cause

HPV infection is caused by a virus.
More than 100
types of HPV have been found. Some types cause
genital warts and some can lead to
cervical cancer. Types 6 and 11 cause most genital
warts. Other types such as 16 and 18 are high-risk and can cause abnormal cell
changes on the cervix.

How the infection is spread (transmission)

HPV is
spread by direct contact.

The virus can be spread to or from the
genitals, anus, mouth, or throat during sexual activities. But warts in the
mouth or throat are extremely rare. Condoms can lower your risk of getting
genital warts.

After the infection occurs, it may spread to other areas of
the genitals or to the anal area.

You can spread the virus even if
you do not have any symptoms of infection or any visible warts.

There is a small chance that a pregnant woman can pass the
virus to her baby.

Symptoms

Human papillomavirus (HPV) infection

Infection
with the
human papillomavirus (HPV) usually does not cause any
symptoms and does not always produce visible
genital warts. Some types of HPV cause cell changes to
the
cervix that can cause an abnormal Pap test.

When symptoms do develop, they usually occur 2 to 3 months after
infection. But symptoms have been known to occur from 3 weeks to many years
after infection.

Symptoms that may occur with genital warts
include:

Irritation.

Itching.

Bleeding.

Genital warts

Genital warts can be different sizes and shapes.

They may be large, or they may be too small
to be seen with the naked eye. They may appear individually or in
groups.

Warts may look like tiny bunches of cauliflower or like
flat, white areas that are very difficult to see.

In women and men,
warts may appear in the groin, on and around the genitals, in the
urethra, or in the
rectum or anus.

In women:

Genital warts may appear around the anus or on the
vulva,
vagina, or cervix.

Women are often unaware of warts
inside the vagina or on the cervix until a doctor finds them.

In men:

Genital warts may occur on the outside of
the penis, on the scrotum, or around the anus.

Men are often unaware they have
genital warts, even when they can be seen, until the warts are identified by a
doctor.

What Happens

Based on the type of HPV, you
may or may not have visible
genital warts.

Common
HPV types 6 and 11 produce visible warts. These warts may go away on their
own, stay the same, or increase in number.

Other HPV types, such as
16 and 18, do not produce visible genital warts. These types, which may be
found with a
Pap test, are linked to precancerous cervical
cell changes and
cervical cancer.

HPV infection and cervical cell changes

In women,
most precancerous or cancerous cell changes associated with HPV infection occur
on the
cervix. This is because the cells of the cervix
naturally undergo changes in an area called the
transformation zone. This process can cause cervical
cells to become abnormal when they are infected with HPV.

Infection with high-risk types of HPV increase the chance that a woman with HPV
will develop abnormal cervical cell changes. It is important to have regular
exams by your doctor. If your doctor finds abnormal cells on a Pap test, the
cells can be treated to help prevent them from changing to cancer.

HPV infection and anal and penile cancer

Among people who receive anal sex, HPV infection of
the anal canal is associated with an increased risk of anal cancer. This risk
may be especially high in men who also have
HIV infection.1

It is not clear
whether men who are infected with HPV on the penis are more likely to have
precancerous or cancerous changes on the penis than men who are not infected.
Because HPV does cause cell changes, more research is being done to find out
whether HPV increases the risk of penile cancer. In the United States, cancer
of the penis is extremely rare.

HPV infection during pregnancy

The presence of
HPV and abnormal cell changes does not affect the outcome of the pregnancy. A
pregnant woman who is infected with the type of HPV that
causes genital warts may have more complicated warts than a woman who is not
pregnant. Genital warts may increase in size, bleed, or become infected with
bacteria. Your doctor may recommend treatment. Warts may be passed on to the
newborn, but this is rare.

What Increases Your Risk

Things that increase a person's
risk for getting a sexually transmitted infection, such as
HPV and
genital warts, include:

If you have a high-risk type of HPV and are using birth
control pills for more than 5 years, research suggests that this can increase
your risk of getting cervical cancer.2 More research
is needed. For more information, see the topic
Cervical Cancer.

When To Call a Doctor

Call your doctor if you have
any of the following symptoms:

Sores, bumps, rashes, blisters, or warts on or
around your genitals or anus

Burning, pain, or severe itching while
urinating

For women, an abnormal vaginal
discharge that smells bad

For men, an
abnormal discharge from your penis

Call your doctor if you suspect you have been
exposed to a sexually transmitted infection (STI).

Avoid sexual contact until you have been examined by a
doctor.

Children

A
child can get genital warts in several ways. Any child who has genital warts
needs to be evaluated by a doctor to find out the cause and to assess for
possible
sexual abuse.

In rare cases, infants may
develop warts in the larynx (laryngeal papillomas), which is in the throat,
from exposure to HPV during birth.

Watchful waiting

A doctor should evaluate any warts or other
symptoms that suggest infection with the human papillomavirus (HPV) or another
sexually transmitted infection (STI). Avoid sexual contact until you have been
examined. If you have an STI, avoid sexual contact to prevent spreading the
virus.

Sometimes, warts may go away on their own. If you have
genital warts, your doctor may observe your condition without using medical
treatment. This is called watchful waiting. This period may vary from a few
days to weeks or possibly months.

The length of the watchful
waiting period is based on:

The severity of your
symptoms.

The progression of the problem if not
treated.

The risks and benefits of waiting.

Your age
and medical history.

Who to see

In general, your family doctor or any of the following
health professionals can determine whether you have genital warts:

Exams and Tests

A doctor usually can diagnose
visible
genital warts using your medical history and a
physical exam. But not all HPV infections cause visible warts. If you
don't have any visible genital warts or other symptoms, it may be hard for your
doctor to diagnose HPV infection. Your doctor may ask you the following
questions:

For women

After your doctor takes your medical
history, you will have a
gynecological exam, which usually includes a Pap
test.

A Pap test screens for abnormal cells on the
cervix. Results of the Pap test may indicate an HPV
infection even though you have no visible warts.

Women over age 30 may
get a screening test for HPV at the same time as a Pap test. This
HPV test looks for the
DNA (genetic information) of the virus. Women under 30
usually get the HPV test only if they have an
abnormal Pap test.3

If your doctor finds areas of abnormal tissue on the cervix (which may be
related to HPV infection), he or she may recommend treatment.

For men

After the medical history, you will have a
physical exam for genital warts.

Doctors do not recommend a screening test for HPV infection in men.

For men and women

Some experts believe that people who receive anal
sex should have a screening for anal cancer, especially if they also have
HIV infection. Ask your doctor whether and how often
you should be tested.

If visible warts are present, a
diagnosis can usually be made without more testing.

Testing
for the type of HPV that is causing warts is not useful for diagnosis. This
test is not routinely done for diagnosis or treatment of genital warts.

Treatment Overview

There is no cure for HPV infection, but
warts and cell changes can be treated. HPV infection that causes an
abnormal Pap test will be treated differently than the
HPV types that cause genital warts.

Genital warts
caused by the most common
types of human papillomavirus (HPV) may go away on
their own without treatment. For this and other reasons, experts sometimes have
different approaches to treating genital warts.

Genital warts may disappear without treatment.
This is the natural course of many genital warts.

Destroying
large areas of warts is difficult and may cause scarring.

Treatment
for genital warts does not eliminate the HPV infection. You may still be able
to spread the infection. Condoms can help reduce the risk of HPV
infection.

Treatment of genital warts can
be painful, and warts may return after treatment. Warts that return after being treated usually
are not treated again unless you want to be retreated. If you do, you would
usually choose a different form of treatment.

Some doctors believe that treatment for genital warts will help
prevent the spread of HPV infections and keep genital warts from
returning.

Types of treatment

Treatments for genital warts
include medicines, freezing, laser, or surgery.

If you are pregnant. Some wart medicines should not be used
during pregnancy.

Medicines

Doctors often recommend medicine
applied to warts (topical drug treatment) as the first choice of treatment. A
doctor will apply the medicines that have a high risk of causing damage to the
skin around the warts. You can apply others at home.

Caution: Do not use nonprescription wart removal products to
treat genital warts. These products are not intended to be used in the genital
area and may cause serious burning.

Surgery and other treatment

Surgery to remove
genital warts may be done when:

Medicine treatment has failed and the
removal of warts is considered necessary.

Warts are
widespread.

What to think about

Without treatment, external
genital warts may remain unchanged, increase in size or number, or go away.
Studies show that no one treatment is completely successful. All treatments have advantages and disadvantages. The
benefits and effectiveness of each treatment need to be compared with the side
effects and cost.

Treatment of warts usually requires a series
of applications rather than a single treatment.

Warts in moist
areas usually respond better to treatments applied to the area, such as creams
or acids.

Warts on dry skin may respond best to freezing
(cryotherapy) or surgical removal.

Cryotherapy may
be done when genital warts are visible and bothersome and are growing in a
small area. Repeat treatments may be needed to remove all wart
tissue.

The success of surgery is related to the number of warts.
The success rate is higher and additional treatments are less likely to be
needed when surgery is done on fewer and smaller warts. But surgery is
less likely to be needed for a few small areas of warts. Surgery may require
anesthesia.

Small areas of warts can be quickly treated with
removal methods, such as cryotherapy or surgical
excision.

Self-applied medicines may be used for larger areas of
warts that need longer or repeated treatments.

A
biopsy of warts that do not go away on their own or
after treatment is often done to rule out precancerous or cancerous
conditions.

Several choices of
treatment for pregnant women have been found to be
effective and safe, including trichloroacetic acid (TCA), cryotherapy, and
surgery.

Prevention

You can reduce your
risk of becoming infected with the
human papillomavirus (HPV) or another
sexually transmitted infection (STI). You also can
reduce the risk of spreading HPV to your sex partner(s).

Practice safer sex

Talk with your partner about STIs before
beginning a sexual relationship. Find out whether he or she is at risk for an
STI. Remember that it is possible to be infected with an STI without knowing
it. Some STIs, such as
HIV infection, may be in your blood for 3 to 6 months before
they can be detected.

Be responsible.

Avoid sexual contact if you have symptoms
of an STI or are being treated for an STI.

Avoid sexual contact
with anyone who has symptoms of an STI or who may have been exposed to an
STI.

Having several
sex partners increases your risk of getting an STI.

Male condom use

Condom use can
reduce the risk of becoming infected with HPV. You can reduce the risk of infection
if you use a condom every time you have sex. Condoms must
be put on before beginning any sexual contact.

Female condom use

Even if you are using another
birth control method, you may wish to use condoms to reduce your risk of
getting an STI.
Female condoms may lower the risk of
HPV infection of the cervix, but they do not cover all of the vulva. These condoms are more effective at lowering
the risk for other STIs.

Vaccines

If you are age 26 or younger, you can get the HPV shot. The vaccines Cervarix(What is a PDF document?) and Gardasil(What is a PDF document?) protect against two types of HPV that cause cervical cancer. Gardasil also protects against two types of HPV that cause genital warts. Three shots are given over 6 months. It is recommended for children age 11 or 12, but can be given as early as age 9. For girls who have not already gotten the vaccine, it is recommended up to age 26. For boys who have not already gotten the shot, the vaccine is recommended up to age 21. Gardasil is used for males. Females can get either vaccine.

The HPV vaccine is not useful for treating women who
already are infected with HPV.4 But it may protect a
woman against types of the HPV virus other than the one causing her
infection.

Home Treatment

Home treatments may not cure HPV infection and
genital warts. But a doctor may prescribe medicine
that you can use at home, such as
podofilox lotion or gel or
imiquimod cream.

Caution: Do not use nonprescription wart removal products to
treat genital warts. These products are not intended for the genital area and
may cause serious burning.

You can use at-home care to feel more
comfortable.

Take sitz baths. Fill a tub with a few inches
of warm water and sit in it for 10 or 15 minutes every day.

Squeeze
warm water from a bottle over your genital area to provide comfort and
cleansing.

Use a heat lamp or a hair dryer several times a day to
dry your genital area. Make sure to hold the lamp or dryer at least 18 inches
from your skin.

It is important to remember that most infections are minor,
without serious complications. Some cases of HPV infection and genital warts disappear
without treatment, although human papillomavirus (HPV) may still be present in
your body's cells.

Medications

Medicine may be used to destroy
bothersome
genital warts, relieve your symptoms, and reduce the
amount of area affected by warts, particularly when the warts are:

Visible, bothersome, and growing in a small
area.

A cosmetic concern and you want them removed. Warts that are
growing around the anus or on external genitals, such as on the penis or
vulva, may be removed because they are unsightly. Some
treatments that remove genital warts are more likely to leave scars. So
cosmetic concerns about scarring may help guide the choice of treatment.

Topical medicine often is the first treatment. For safety,
a doctor will apply the topical medicines that could damage the skin around the
warts. You can apply other medicines at home. If warts return after one course
of treatment with topical medicine, they are treated again only if there are
clear reasons for retreatment.

Medicines are not used to treat
abnormal cell changes found on a Pap test. For more information on treating
abnormal cell changes caused by high-risk HPV, see the topic
Abnormal Pap Test.

Treatment applied at home

The following
medicines can be applied to the affected area (topical treatment) at
home:

Imiquimod
(such as Aldara)

Podofilox lotion or gel (such as Condylox)

Sinecatechins (such as Veregen)

Do not use these medicines during pregnancy.

Imiquimod and podofilox are typically the most effective medicine options
that can be applied at home. Read the instructions carefully before using these
medicines.

Treatment applied by a doctor

Treatment by a
doctor can:

Treat areas that you cannot reach
easily.

Treat a large area.

Remove the warts
quickly.

Be expensive.

Be painful.

Have
side effects.

Medicines applied by a doctor include:

Trichloroacetic acid (TCA) or bichloroacetic acid (BCA).

Podophyllin resin.

Intralesional
(injected into wart lesion)
interferon.

Fluorouracil
(such as Efudex).

Treatment during pregnancy

Treatment for pregnant women includes trichloroacetic acid (TCA) and
bichloroacetic acid (BCA), which have been found to be both effective and safe.
Podophyllin resin, interferon, and fluorouracil should not be used during
pregnancy, because they can harm the fetus.

What to think about

Avoid sexual contact in the
treated area until the area is completely healed.

Some medicine
may be more expensive than others.

Warts on the vulva or penis
that do not go away on their own or after treatment often are
biopsied to rule out precancerous or cancerous
conditions.

Recurrence

Removing genital warts does not cure
an HPV infection. Warts may go away with topical treatment, but they may
return, because HPV may still be in the body's cells.

Even if genital warts have been removed or destroyed:

You may still be able to infect sex
partners with HPV.

You should continue to use condoms during sexual
intercourse if you have multiple sex partners.

Surgery

You may have surgery to remove
genital warts if they are widespread and medicine or
freezing (cryotherapy) fails to remove them.

If you have a
high-risk type of HPV that causes an abnormal Pap test, your doctor may
recommend certain types of surgery. For more information about surgical methods
to treat abnormal cell changes, see the topic
Abnormal Pap Test.

Surgical treatment for pregnant women

What to think about

The success of surgery is
related to the number of warts present. The success rate is higher and
additional treatments are less likely to be required when surgery is done
on fewer and smaller warts. But surgery is less likely to be needed for a few
small areas of warts.

Centers for Disease Control and Prevention (2011). Recommendations on the use of quadrivalent human papillomavirus vaccine in males: Advisory Committee on Immunization Practices (ACIP). MMWR, 60(50): 1705-1708. Also available online: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6050a3.htm?s_cid=mm6050a3_e.

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